PFD Response Tracker

Prevention of Future Deaths

Total: 1,424 Responded: 0 No identified response (past 2 years): 0 Pending: 0 Historic with no identified response: 1,424

How statuses are calculated — 56-day deadline, Judiciary.UK data

Recipients have 56 days to respond under Regulation 28. We use the deadline stated in the report where available, otherwise we calculate it from the report date. We rely on Judiciary.UK for response data, so if a response has been provided but not yet published there, it may show incorrectly here. "No identified response", "Pending", and "Historic" only count reports where no response at all has been identified as published on Judiciary.UK. If at least one response has been published for a report, it counts as "Responded" — even if not every listed addressee has a separate published response. This is because addressee data from Judiciary.UK can be unreliable: address fragments, job titles, and redacted names are sometimes parsed as separate addressees, and a single response PDF may cover multiple parties. "Historic with no identified response" means we have not been able to identify a published response, but the report is more than two years old. We do not mark these as overdue or pending because older reports may well have received a response that was simply never made public. This is a neutral status indicating absence of an identified published record, not confirmed non-compliance.

2 reports include a non-response confirmed by the Chief Coroner. Show only confirmed

Historic Clear all

Filters

Keyword Search

Response Status

Response Confidence

Organisation

Category

Coroner Area

Date Range

Clear

1,424 reports · Page 27 of 29

Date	Deceased	Addressee(s)	Status	Responses
4 Feb 2014	Neil Blood A lack of regulatory oversight, risk assessment, and consumer warnings for pedal cycle cleats and shoes raises concerns …	Department for Transport Shimano Inc	Historic (No Identified Response)	0/2
4 Feb 2014	Samuel Boon The expedition lacked adequate risk assessments, failed to provide sufficient pre-trip information, neglected to formally assess participant fitness, …	Department for Education	Historic (No Identified Response)	0/1
3 Feb 2014	Amy Friar The absence of universal emergency codes across the prison estate creates confusion for transferring staff, risking delays in …	Ministry of Justice	Historic (No Identified Response)	0/1
3 Feb 2014	Daniel Collins The provided text indicates that matters of concern were revealed but does not detail what these specific concerns …	Devon and Cornwall Police Plymouth City Council	Historic (No Identified Response)	0/2
3 Feb 2014	Michael Telford	Cumbria County Council	Historic (No Identified Response)	0/1
3 Feb 2014	Scarlett Sinclair The policy for assessing a baby's wellness and stability prior to transfer between neonatal units needs urgent review, …	Oxford University Hospitals NHS Trust	Historic (No Identified Response)	0/1
31 Jan 2014	Ryan Chapman Staff lacked understanding of patient leave policies and support worker roles. Delayed risk assessments, insufficient family information, and …	Sussex Partnership NHS Trust	Historic (No Identified Response)	0/1
31 Jan 2014	Shaun Elliott The coroner noted that a missing person coordinator was not in post at weekends, that Shaun's family expressed …	College of Policing	Historic (No Identified Response)	0/1
31 Jan 2014	William Kent Staff lacked awareness and received insufficient training on the harmful side-effects of Haz-Tab granules when used with urine, …	Guest Medical Medicines and Healthcare products Regulatory … St Peter’s and Ashford Hospitals	Historic (No Identified Response)	0/3
30 Jan 2014	Gareth Slater Discharge planning failed due to clinical impasses, resulting in no care plan, insufficient family involvement, inadequate independent living …	Oldham Borough Council Pennine Care NHS Foundation Trust	Historic (No Identified Response)	0/2
27 Jan 2014	Pamela Bailey Delays in implementing improved door security, inadequate weekend staffing, and the lack of a patient photograph for police …	Sheffield Trust	Historic (No Identified Response)	0/1
26 Jan 2014	Lillian Robinson The report text did not detail specific concerns, only indicating that matters giving rise to a risk of …	Surrey County Council	Historic (No Identified Response)	0/1
24 Jan 2014	Elizabeth Turnbull The close proximity of thumbwheel controls, coupled with the absence of dual controls, increased the risk of inadvertently …	British Industrial Truck Association HM Principle Specialist Inspector	Historic (No Identified Response)	0/2
23 Jan 2014	Desrae Tucker Inadequate recording of anti-embolic stocking use, no consideration for discharging the patient with them, and failure to prescribe …	Aneurin Bevan Health Board	Historic (No Identified Response)	0/1
22 Jan 2014	Paul Rogerson River safety equipment is inadequate, poorly maintained, and lacks proper warning signs. Gaps exist in police river rescue …	City of York Council North Yorkshire Fire and Rescue … North Yorkshire Police	Historic (No Identified Response)	0/3
21 Jan 2014	Christine Nutbeam Critical information about a patient's symptoms was not transferred between hospitals or communicated to surgical teams, and pre-operative …	St Peter’s Hospital Wexham Park Hospital	Historic (No Identified Response)	0/2
21 Jan 2014	Kyle Ashley Smith An urgent mental health referral from a GP was significantly delayed in reaching the assessment team, with the …	Longshoot Health Centre	Historic (No Identified Response)	0/1
21 Jan 2014	William Dowling & Victoria Rose There's no national system allowing doctors to proactively share concerns about a patient's ongoing suitability for a firearms …	Association of Chief Police Officers British Medical Association Firearms and Explosive Licensing Working … Hampshire Constabulary Criminal Justices and Victims, House … Minister of State for Victims … Wiltshire Clinical Commissioning Group Wiltshire Constabulary	Historic (No Identified Response)	0/8
21 Jan 2014	John Malone A hospital discharge letter was critically deficient, lacking essential patient admission and discharge details, which hindered the GP's …	Tameside Hospital NHS Foundation Trust	Historic (No Identified Response)	0/1
17 Jan 2014	Julia Dell The medical service received from primary care was exemplary during the period examined, with no concerns identified in …	Royal Cornwall Hospital Trust Medical Centre Stratton, Bude, Cornwall	Historic (No Identified Response)	0/3
16 Jan 2014	James Stokoe Mental Health Services lack formal mechanisms to consult carers/partners, potentially missing vital information that could inform risk assessments …	Department of Health and Social …	Historic (No Identified Response)	0/1
16 Jan 2014	Jackie Scott Lack of clear allergen information meant the deceased unknowingly consumed peanuts in a take-away meal, resulting in a …	Indian Brasserie	Historic (No Identified Response)	0/1
14 Jan 2014	Craig White Concerns include insufficient TB screening protocols before Infliximab treatment, inadequate prescriber awareness of increased TB risk, and the …	British National Formulary British Society of Gastroenterology Intensive Care Society Lincolnshire Community Health Services NHS … Medicines and Healthcare products Regulatory … Phoenix Partnership United Lincolnshire Hospitals NHS Trust	Historic (No Identified Response)	0/7
14 Jan 2014	Russell James Felstead Doctors failed to access and read vital medical information within nursing notes, resulting in a four-day delay in …	Care Quality Commission Stepping Hill Hospital Choice Support	Historic (No Identified Response)	0/3
13 Jan 2014	Barbara White Critical lapses included a 12-hour absence of clinical observations, an incorrect PARS score that should have triggered intervention, …	Tameside General Hospital	Historic (No Identified Response)	0/1
10 Jan 2014	Mary Waldron Nursing home staff failed to recognise and act on an acutely unwell resident due to inadequate ongoing training …	Care Quality Commission Nursing and Midwifery Council St Mary’s Nursing Home West Midlands Ambulance Service University …	Historic (No Identified Response)	0/4
10 Jan 2014	Dr Edward Slaney There is a lack of established criteria and guidance for planning authorities to assess the wind effects of …	Ministry of Housing, Communities & …	Historic (No Identified Response)	0/1
8 Jan 2014	Jonathan Thorpe A GP failed to consult or refer a known self-harmer to Mental Health Services, prescribing medication without adequate …	King Street Medical Centre	Historic (No Identified Response)	0/1
7 Jan 2014	Andrew John Fallon Emergency Department staffing levels were critically insufficient, causing excessive delays for seriously ill patients as staff were overwhelmed …	Stockton NHS Foundation Trust	Historic (No Identified Response)	0/1
7 Jan 2014	James Withers Key concerns include significant delays in specialist consultation, missing medical notes, and poor communication with family regarding the …	Tameside Hospital NHS Foundation Trust	Historic (No Identified Response)	0/1
6 Jan 2014	Chloe Grace Flavell The reception area management, prior to triage, creates significant and dangerous delays in providing immediate care and treatment, …	Weston Area Health NHS Trust	Historic (No Identified Response)	0/1
3 Jan 2014	Keith Fleming The provided text indicates that matters of concern were revealed but does not detail what these specific concerns …	Newcastle upon Tyne Hospitals NHS … North of England Commissioning Report South Tyneside NHS Foundation Trust Trinity Medical Centre	Historic (No Identified Response)	0/4
20 Dec 2013	Roy Frank Fletcher The Trust's post-incident review was inadequate, failing to interview a key witness or assess if similar events were …	Lancashire Care NHS Foundation Trust	Historic (No Identified Response)	0/1
19 Dec 2013	Michael Longley Difficulties in communication between Integrated Care 24 and the District Nursing Service highlight a need for improved oral …	Kent Community Health NHS Foundation …	Historic (No Identified Response)	0/1
17 Dec 2013	Sean Seabourne Systemic communication failures and unclear roles between mental health teams led to an urgent referral for a high-risk …	Worcestershire Health and Care NHS …	Historic (No Identified Response)	0/1
16 Dec 2013	Sarah Shepherd The Trust lacked a clear referral process for PICU and its documentation, while nursing staff misunderstood resuscitation guidelines …	Surrey and Borders Partnership NHS …	Historic (No Identified Response)	0/1
12 Dec 2013	Jane Dyson Gabbitas An open residential unit lacked a formal system to record and monitor resident absences, leading to staff being …	South West Yorkshire Partnership NHS … The Chief Coroner	Historic (No Identified Response)	0/2
12 Dec 2013	Rosemary Brownyn Ferguson Poor communication between hospital staff and Social Services led to a discharge without support. Unclear instructions given to …	Doncaster and Bassetlaw Teaching Hospitals …	Historic (No Identified Response)	0/1
11 Dec 2013	Damion Stanley Joseph Henson A homeless unit, housing drug users, lacked 24-hour supervision, allowing unauthorized individuals to enter out of hours, thereby …	Riverview, 62 Lound Road, Kendal Riverview, 62 Lound Road, Kendal	Historic (No Identified Response)	0/2
9 Dec 2013	Anthony Hughes Police officers lacked awareness of "excited delirium," suggesting that training on this condition could improve responses in future …	National Crime Agency	Historic (No Identified Response)	0/1
5 Dec 2013	Karl Doran The theme park failed to conduct appropriate risk assessments for volunteers, and there was a complete absence of …	Beamish Museum HSE	Historic (No Identified Response)	0/2
5 Dec 2013	Desmond Statton The provided text describes a procedural step (blood sampling) but does not detail any specific concerns.	Derriford Hospital, Plymouth	Historic (No Identified Response)	0/1
4 Dec 2013	Keith Thomas Graham The report identifies a need to review procedures for seriously injured trauma patients arriving at the A&E, including …	North Cumbria University Hospitals NHS …	Historic (No Identified Response)	0/1
3 Dec 2013	Horace Cottom	Secretary of State for Health the NHS HMPS HMP Manchester major NHS Trusts in Greater … Minister for Prisons	Historic (No Identified Response)	0/6
3 Dec 2013	Agostino Costa Staff confusion over patient falls risk classification and junior doctors' lack of training in post-fall management created significant …	The Whittington Hospital NHS Trust	Historic (No Identified Response)	0/1
2 Dec 2013	Karl Olof Nilsson The junction's layout, gradient, and an obscured STOP sign created an optical illusion, making the sign difficult to …	National Highways Bradford Metropolitan District Council	Historic (No Identified Response)	0/2
1 Dec 2013	John William Tugwell The care home allowed a high-risk patient with a documented history of falls unsupervised access to stairs, despite …	Coombe Dingle Nursing Home	Historic (No Identified Response)	0/1
28 Nov 2013	Doris Phoebe Miller Patient medical records were unavailable to the GP surgery after a practice closure, indicating a failure in transferring …	Care Quality Commission NHS England Hertfordshire and South …	Historic (No Identified Response)	0/2
27 Nov 2013	Christopher Scott The 'legal high' AMT is readily available for purchase despite clear evidence of its deadly effects, raising concerns …	House of Commons	Historic (No Identified Response)	0/1
26 Nov 2013	Alan Stanfield Browning A vulnerable patient was discharged from a care facility without family notification or proper accommodation arrangements, specifically on …	Somewhere House	Historic (No Identified Response)	0/1

Neil Blood